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R y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F4r� OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> E Teleph`onc: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> , v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUE. Date Issued `V-' 7-76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in .compliance with San Joagr`in <br /> County Ordinance_No...1"862--and the Rules and Regulations of the San Joaquin Local Health Dig,,tric <br /> 7i-3S16 02Q��c701- <br /> JOB A�6/LOCATION �5_0Q V C�fTJt rA4,l�AV AfE �fl,S CENSUS TRACT " <br /> Owner's Name /�&KC, Be:�Z�f $ � 3SV Phone O <br /> '- <br /> Address Q ,0 �.E@3E5 City _ ,'v�T � <br /> ' '37' <br /> Contractor's Name p License #33]f. �Phane �$ ^7 <br /> f TYPE OF WORK-(Check) : —NEW—WELL /�/ DEEPEN_/----/--RECONDITION- DESTRUCTION, / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / I <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _q4- SEWER LINES 5-0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE RIVATE DOMESTIC WELL .-S PUBLIC DOMESTIC WELL <br /> INTENDED_.USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial fable Tool Dia. of Well Excavation E' l5T/ t� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing O <br /> L..—Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type .of Grout �---� <br /> Disposal , Other Other Information <br /> ' Geophysi`ca1. Surface Seal Installed By: <br /> c; <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump .- H.P _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / St-a"te_Wo rk Done- - .-----..� <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material a Procedure: <br /> I hereby agree to comply with all law's'.-gad regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> € after completion of my work on a new well, I will furnish the San Joaquin Local Health District -a <br /> WELL DRILLERS REPORT of the well and notify them before putting- the well in use. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ' PRIOR TO GROUTTXG ANDA FINAL�-IN $4-0N: <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> n!%7 2M <br /> E H 1426 Rev. � 1-74 <br />